Not Just Vanity: Tummy Tucks That Heal -More patients are opting for tummy tucks or other “body contouring” procedures after serious weight loss or bariatric surgery that aren’t just about vanity: they lessen the risk of infection and improve healing after surgery. Laura Landro reports.

Lizanne Haddadin of Discovery Bay, Calif., had a dual hernia-and-abdominoplasty surgery after her 120-pound weight loss left her with excess skin and some belly fat. Photo: Miami Plastic Surgery.

More people are getting tummy tucks and other so-called body-contouring procedures after losing a large amount of weight. While vanity may play a role in the decision to have such a surgery, new research shows that there are significant health benefits to these operations, including motivating patients to keep their weight in check.

Tummy tucks, officially known as abdominoplasty, aren’t typically covered by insurance. But they have become more common following bariatric surgery, which reduces the size of the stomach to help patients reduce food intake and lose weight. And unlike in the past, some surgeons are often more willing to perform the procedures in tandem with other types of abdominal surgery, as recent studies show there aren’t generally major complications from combining the procedures.

A study in the October issue of Plastic and Reconstructive Surgery by Swiss researchers found that bariatric patients who have surgery to remove excess skin are more likely to keep weight off after procedures, regaining an average of just over 1 pound a year compared with 4 pounds annually for bariatric patients who didn’t have contouring procedures.

The authors say the findings add to the argument that such procedures are an essential part of successful weight-loss surgery and should be considered reconstructive and thus covered by insurance.

More patients are opting for tummy tucks or other “body contouring” procedures after serious weight loss or bariatric surgery that aren’t just about vanity: they lessen the risk of infection and improve healing after surgery. Laura Landro reports. Photo: Miami Plastic Surgery.

These surgeries can produce “a second wave of elation” that helps a patient stay on track to lose more weight, says Tripp Holton,    assistant professor of plastic surgery at the University of Maryland School of Medicine.

Many people who finally reach a goal of losing 50 or 100 pounds or more through diet and exercise or bariatric surgery find themselves with a new and frustrating dilemma: sagging extra skin and stubborn deposits of belly fat.

Lizanne Haddadin  of Discovery Bay, Calif., lost 120 pounds over about eight years by watching her calories and regular workouts. When she had hernia surgery in July, Ms. Haddadin, a special-education teacher’s aide and mother of two, opted to have a tummy tuck at the same time to remove excess skin and fat she couldn’t shed after the weight loss and to tighten her abdominal muscles.

After her dual surgery, she came home with a pump to deliver pain medicine directly to the stomach area for five days, and had a licensed vocational nurse stay with her for 24 hours to help with bandages and drains. She says she was able to get by with minimal use of pain medication, and she took antibiotics to prevent infection, with no complications.

Ms. Haddadin, 46, was walking slowly on her treadmill a couple of weeks after surgery and is now jogging, hiking, swimming, weight lifting and taking exercise classes.

“I feel like clothes fit me better and I feel much better when I jog and exercise,” she says. “I was really uncomfortable having all that extra skin.”

Since the surgery, Ms. Haddadin, who is 5-foot-6, has lost an additional 15 pounds and is down to 176 pounds. Her eventual goal is 135 pounds. “I have a ways to go, but this has helped me get closer to my goal,” she says.

Ms. Haddadin says she felt the dual surgery was also cost-effective: Alameda, Calif.-based Rex Moulton-Barrett,  the plastic surgeon who performed her surgery, included the hernia repair in his fee for the tummy tuck. The total cost, including surgery, anesthesia, the nurse and rental of a hospital bed for her home for 30 days, was about $8,000.

A study of 20 of Dr. Moulton-Barrett’s patients, published in the February issue of Plastic and Reconstructive Surgery, found that tummy tucks led to significant and lasting weight loss for many patients, especially those who were overweight and obese. Long-term weight loss was more likely for women in the study who were just under the borderline for overweight. And sustained weight loss was also more likely for those who had a greater amount of excess abdominal tissue removed.

Dr. Moulton-Barrett says increased satiety seemed to be an important contributor. And the study provides preliminary evidence that removing fat cells in the abdomen may lead to reduced levels of appetite-affecting hormones, which are secreted by fatty tissues, he says.

This was Ms. Haddadin’s experience. She says she gets less hungry and feels fuller sooner at meal times.

Like many surgical procedures, tummy tucks carry risks including infection and blood clots. But a study at Montefiore Medical Center in Bronx, N.Y., presented last April at the American Association of Plastic Surgeons’ annual meeting, found there was no evidence of an increase of complications among obese or even morbidly obese patients who had abdominoplasty 12 to 18 months after gastric-bypass procedures. The researchers noted that many such patients benefit from body-contouring surgery to improve daily-life activities.

After the Fat

These body-contouring procedures reduce fat or skin left behind after weight loss.

• Tummy tuck: removes excess fat and skin in the abdomen
• Panniculectomy: eliminates the ‘apron’ of sagging skin below the belly button
• Lower-body lift: removes the ‘belt’ of excess skin and fat from thighs, buttocks, hips and waist
• Arm lift: diminishes upper-arm area skin and fat, alone or with liposuction
• Face/neck lift: removes loose skin and jowls around the face and neck
• Medial-thigh lift: lifts and tightens sagging skin of the inner thigh

Source: The American Society for Aesthetic Plastic Surgery

While some surgeons avoid performing tummy tucks in tandem with other abdominal surgeries, citing evidence of higher complications, University of Maryland’s Dr. Holton says he performs contouring procedures with hysterectomies and for obese, diabetic patients having kidney transplants. Removing extra skin and fat in the abdomen can lessen the risk of infections that frequently occur in the folds of excess skin. It can also improve healing after surgery, he says.

“Combining surgeries is very reasonable. And when done safely it is a good strategy to avoid exposing patients to two separate episodes of general anesthesia—and to decrease the chance of wound infection,” Dr. Holton says.

He has sometimes contacted a health insurer, he says, to argue that procedures to remove excess skin are medically necessary in those patients.

In some cases, plans will pay for a separate procedure called a panniculectomy, which can be performed alone or in combination with a tummy tuck. It removes the pannus—an “apron” of skin and tissue from below the belly button that can hang as low as the knees, can’t fit comfortably into clothing and can cause back pain and serious skin issues, including infections and ulcers.

A typical tummy-tuck procedure removes two to 10 pounds of belly fat by disconnecting the skin from underlying tissues, tightening the abdominal muscles with sutures and trimming away excess skin.

In some cases, doctors remove fat deposits using liposuction, and remove excess skin and fat in the sides or back with an additional body-lifting procedure.

Since 2000, the number of tummy-tuck procedures has risen by 70% to more than 106,000, according to the American Society of Plastic Surgeons.

Write to Laura Landro at laura.landro@wsj.com

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“I wanted to look bigger but I don’t want to be like falling over, and I didn’t also want to see like you cant see change from what I had before, so I think my biggest issue was getting that right size without overdoing it,” Stephanie Cristobal said.

To see what she will look like after surgery, Cristobal had her picture taken with the Vectra system at Miami Plastic Surgery. Six cameras take simultaneous photos to create 3D images of the patient. The system also features before and after animation.

“And then we can literally try different implants from different manufacturers inside of that picture and show them how different size implants are going to look,” said Dr. Michael Kelly of Miami Plastic Surgery.

Breast augmentation is the most popular plastic surgery in the country. Last year more than 300,000 women got implants.

But choosing the right one can be tricky.

“I never have patients who come back to me after surgery and say you made me too big – never see it,” Kelly said. “But I do see patients, especially at a year after surgery, who say you know what, I love my implants, I love the way I look, but if I had to do it all over again I’d go a little bit bigger. So I think this will help us in that process.”

The Vectra system also gives the surgeon useful information like the exact volume of each breast.

“So that helps us in planning because sometimes we need to use a bigger size implant on one side versus the other, so this is helpful for that,” Kelly said.

Overall, patients get a better idea of what to expect.

“I think it’s insane how our technology is so highly advanced, and we’re now finally able to see what we would look like after surgery, before the surgery,” Cristobal said

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Lawsuits Involving Laser Treatments by Non-Docs on the Rise

Medical-grade lasers can cause burning and cell damage to skin, experts warn.

By Steven Reinberg HealthDay Reporter

WEDNESDAY, Oct. 16 (HealthDay News) — A growing number of lawsuits over damage from skin laser treatments are tied to procedures done outside of medical offices and by non-doctors, a new study finds.

“This does not shock me,” said Dr. Robert Murphy, president of the American Society of Plastic Surgeons. “We encourage the consumer to know who their physician is and know what their qualifications are as a basic requirement for entering into any treatment.”

Lead study researcher Dr. Hrak Ray Jalian, who’s with the division of dermatology at the University of California, Los Angeles, said these procedures can cause harm if not done correctly.

“With this in mind, patients should know the qualifications, certifications and experience of the individual performing their procedure,” Jalian said. “Because of the lack of uniform regulations, just because a person is legally able to provide the service doesn’t mean they are necessarily qualified to do so.”

Given the increasing number of laser procedures being done, Jalian said he expects the number of lawsuits related to these procedures by untrained people to increase as well.

The report was published Oct. 16 in the online edition of the journal JAMA Dermatology.

These procedures often are done by people employed by doctors’ offices or in other so-called medical facilities, Murphy said. “But they operate in an independent fashion, either not under the direct supervision of a physician or acting independently in spas or the like,” he said.

The powerful lasers used for these treatments can cause skin burns and cell damage when used by poorly trained people, Murphy said.

For the study, Jalian’s team used data from an online U.S. database of public legal documents to identify the number of lawsuits related to skin laser surgery not done by doctors.

The researchers found 175 cases filed from 1999 to 2012. Of these, 75 involved a laser skin procedure not done by a doctor.

Since 2008, the number of lawsuits involving treatment by practitioners other than doctors has risen from about 36 percent of all cases to nearly 78 percent in 2011, the researchers said.

“Another interesting trend was that many of these cases that resulted in lawsuits were performed outside of a traditional physician’s office, such as in so-called ‘medical spas’ — 64 percent of the total cases, and roughly 80 percent of the cases from 2008 to 2012,” Jalian said.

Dr. Jeffrey Salomon is an assistant clinical professor of plastic surgery at Yale University’s School of Medicine. He said that “because medical-grade lasers and intense pulsed light has the potential to harm patients, they are considered prescription medical devices and are therefore subject to [U.S. Food and Drug Administration] statutes and state medical board regulations to ensure that the devices are sold and used by physicians, dentists, podiatrists, optometrists or veterinarians.”

These regulated devices must be used under the supervision of doctors, but state laws vary on how “supervision” is defined, he said.

“Some require a doctor on premises, others do not,” Salomon said. “The state laws also vary regarding acceptable personnel that can be supervised and the amount of training required for those non-physician operators. Physician assistants, nurse practitioners, registered nurses and physical or occupational therapists qualify in almost all states. In some states that may include medical assistants, aestheticians, cosmeticians and nail technicians.”

In the study, the most common laser procedure done was hair removal. And although one-third of those procedures weren’t done by doctors, they accounted for 75.5 percent of cases from 2004 to 2012 and 86 percent of cases between 2008 and 2012, the researchers found.

Generally, laser hair-removal devices are considered by the FDA as class 2, or medium-strength, devices, Salomon said. “But treating a patient or a client with any type of light energy can cause permanent damage simply when too much light energy is administered to a given area of skin,” he said.

Darker skin absorbs significantly more light energy than light skin, so for any given level of laser energy, darker skin will get quite a bit hotter than light skin. “The hotter the skin, the greater the risk of burn or scar formation,” he said.

In addition to hair removal, lasers are used to resurface skin and lessen wrinkles, as well as remove spots and other skin discolorations, Salomon said.

Lasers also can result in damage to eyes if proper precautions and safety rules aren’t followed, he said.

“A certificate indicating proof of training on the laser should be readily provided on demand when a patient wants to check the credentials of the user of the laser,” Salomon said. “Always look for an experienced laser provider who is also comfortable treating your specific skin type.”

More information

For more about cosmetic laser procedures, visit the American Society of Plastic Surgeons.

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